Kenichiro Yagi, MS, RVT, VTS (ECC), (SAIM), Chief Veterinary Nursing Officer for Veterinary Emergency Group 

Can you give our readers a little bit of background about yourself?

I’m a veterinary technician specialist in Emergency and Critical Care as well as Small Animal Internal medicine with 24 years of experience, starting as a veterinary assistant and growing up in a 24/7 general/emergency practice. Today, I am the chief veterinary nursing officer at Veterinary Emergency Group (VEG) overseeing over 2100 veterinary nurses and assistants in 88 hospitals.

What are the most critical physical signs that indicate a patient is in respiratory distress?

Glazed over eyes, lack of awareness, significant effort in breathing that looks like exhaustion, paradoxical breathing (chest and abdomen moving in different directions), and variable rate in breathing (fast sometimes, slow down in between) are all signs of severe respiratory conditions that will lead or respiratory and cardiac arrest. There are plenty of ways we can assess a patient’s respiratory status through visual (face, posture, breathing patterns) and auditory (breathing sounds, lung sounds) to catch respiratory distress before the situation becomes critical.

In what ways can a technician's immediate response impact the outcome for an animal in respiratory distress?

Respiratory conditions ultimately lead to lack of oxygen delivery to the heart, which leads to cardiac arrest. Being able to quickly respond and improve oxygen intake for the patient will buy them the time while the underlying causes of the respiratory condition is treated. While quickly intervening to address the patient’s medical need is important, equally important is alleviating the patient’s suffering (in this case, the feeling of suffocation and exhaustion) as soon as possible.

How does understanding the underlying causes of respiratory distress help in determining the appropriate emergency intervention?

Understanding the underlying causes of respiratory distress is crucial because it allows veterinary professionals to identify whether the issue is primarily due to airway obstruction, gas exchange impairment, or a circulatory issue, which in turn guides the interventions. For example, if the distress is due to an upper airway obstruction, interventions like providing a clear airway (e.g., removing the obstruction, intubating, tracheostomy or sedation) are necessary, whereas pulmonary edema due to congestive heart failure would require diuretics and oxygen therapy. Knowing the cause helps prevent inappropriate treatments (e.g., fluids in a patient with fluid overload) and ensures that interventions target the actual problem, such as improving ventilation in hypoventilation cases or addressing circulation in perfusion deficits.

Articles

Ken Yagi, MS, RVT, VTS (ECC), (SAIM), explains more about respiratory emergencies, and the role technicians can play in saving these patients, topics he was presenting at the 2024 Southwest Veterinary Symposium.

Q&A with Ken Yagi, MS, RVT, VTS (ECC), (SAIM)

Editor’s note: All names and businesses in this dilemma case are fictitious, but the scenario is based on real occurrences.

Competitive, cutting-edge veterinary practices are always looking to put their best foot forward. Pets should be capably cared for and clients treated with respect in an environment that is both supportive and professional. A client’s initial impression when entering a clinic is very important. Staff members and administration rarely think about the effect of a basic initial greeting. Employees at Ocean Animal Clinic recently had this brought to their attention. As a result, they decided to look into this simplest of veterinary encounters.

The previous week, a woman in her 80s came to the clinic with her adult granddaughter and her 6-year-old poodle. When it came time for the appointment, a young veterinary technician approached the clients and said, “Margaret, would you and Fluffy please follow me?” After an uneventful visit, the older woman’s granddaughter pulled the technician aside to speak with her. She said, “My grandmother, Margaret Thompson, is the matriarch of our family and a retired CEO. When you address her, it should be in a respectful manner, and you should not assume that you are on a first name basis.” The technician responded by saying that she certainly did not mean to offend and that this was the way they normally call clients into the exam room. The granddaughter said when her grandmother met the examining veterinarian James White, it was not expected that she would immediately address him as James. The hospital administrator agreed that addressing clients by their first name in a professional setting could be considered presumptuous and even rude. In many cases, it has become the norm in medical settings—partially due to privacy issues and the desire not to use a patient’s surname in a public setting.

This triggered a discussion by the clinic’s administrative team. How do you address a client respectfully without violating their privacy? The most common practice seems to be either announcing a client’s last name for all to hear or addressing the client by their first name. Neither of these greetings is professionally courteous, and to many may be considered rude. Several suggestions were made. It was noted that in some areas of the South, addressing a man or a woman by first using 

in front of their first name was a sign of respect, such as, “Good morning, Miss Margaret. How are you?” Another suggestion uses a first name and last initial when greeting a client in a public waiting area. It was decided the most appropriate way to initially address a client is to simply ask, for example: “Good morning, I’m technician Judy. How would you like me to address you?” The client’s preference could be asked when their initial appointment is made and then noted in their record.

The Ocean Animal Clinic incorporated these changes into its client intake protocols. Several staff members felt that this was an overreaction to a problem that occurred so infrequently that it was not relevant. The hospital manager did not agree. She believed that every pet owner should be treated as courteously as possible. Additionally, how closely a client listens to information about their pet’s follow-up care directly correlates with the animal’s home care treatment. When a client is greeted professionally and courteously, they are more likely to hear and apply the post visit care instructions.

This dilemma is only partially about how to professionally address clients when they come to your veterinary facility. I don’t think anybody really wants to hear their staff yelling someone’s last name for the whole waiting room to hear and then adding the word 

to it, eg, “Thompson, next!” This clearly illustrates the importance of small details. The most successful practices, and the least frustrating workplaces, attend to the small details. The phrase “the devil is in the details” could not be more accurate.

Addressing clients in a respectful and courteous manner
may require change in a clinic’s protocols

What’s in a name?

Supporting new graduate rural veterinarians

Being a newly graduated veterinarian can be a challenging time, and Becky Dickinson, BVetMed (Hons), MVSc, wanted to do something to help, leading her to embark on a novel business idea – setting up Veterinary Support Services. The services offer external locum veterinary support to rural practices to accompany their veterinary graduates on farm calls and support them after-hours to mentor and support them in a structured way.

Becky Dickinson, BVetMed (Hons), MVSc, lancing abscess (Image courtesy of Veterinary Support Services) 

“Our aging population of production animal [veterinarians] and the sustainability of Australia’s rural veterinary services concerns me deeply,” explained Dickinson, exclusively to 

“I had long thought about the challenges new graduate [veterinarians] face in embarking on their large animal career, hearing many horror stories along the way, and watched closely as we continually lose young [veterinarians] to our small animal colleagues early in their career often due to lack of support on the road and difficultly obtaining confidence and clinical competence under the critical eyes of experienced producers.”

Veterinary Support Services provides clinical, practical, educational and mentoring support for recent veterinary graduates in mixed animal practice by accompanying the graduate in their vehicle to large animal call outs.

“We work alongside the graduate on farm as they carry out as much of the veterinary task as they can, guiding, teaching new skills, ensuring safe practices are followed and helping to improve their confidence as they gain competence in their large animal veterinary, communication, and psychosocial skills and develop independence in their general veterinary on-call duties,” said Dickinson.

“Veterinary Support Services also develops and delivers graduate-focused, practical-oriented continuing professional development. These educational events provide 'real world' practical training for management of common livestock health problems, education on mental well-being and development of professional and personal skills.”

Dickinson said that there are multiple goals to the service.

“By supporting, educating, and holistically improving graduate confidence and competence in the field, we are also supporting their rural veterinary practices by alleviating the pressure and demand on senior veterinary practitioners as they perpetually employ and train graduate vets,” explained Dickinson.

“We want to promote rural veterinary sustainability through career and professional support in order to create business models where graduates can thrive across all aspects of mixed animal clinical work and fostering careers in rural veterinary practice. It’s also about enabling the provision of high quality veterinary services to producers regardless of the attending [veterinarian’s] level of experience.”

Earlier this year, Dickinson was approached by the Cattle Compensation and Advisory Committee which represents cattle producers in the state of Victoria, to apply for a grant to expand the work of Veterinary Support Services.

In August, it was announced that Veterinary Support Services had received almost AU$1.5million from the Victorian State Government to deliver a 2-year structured Victorian Livestock Veterinary Scholarship Program for eight early career veterinarians across regional Victoria commencing in January 2025.

“My vision for Veterinary Support Services was always to be able to roll out our graduate support services across the state and then more widely across Australia as I gained business experience and support and recognition from the veterinary profession. I had anticipated that this would take several years before I could embark on this growth so to then be successful in securing funding to carry this out only two years after starting the business was gobsmacking and completely overwhelming,” said Dickinson.

“Pre-program planning is now underway as we advertise and market these scholarships widely within veterinary and agriculture networks. We are also currently busy developing tools and proform as for graduate clinical assessment, application shortlisting and interviewing and forming a comprehensive and structured training program for the candidates and their supervisors.”

Dickinson anticipates being able to announce the successful candidates and their practice locations in early December ahead of commencing the program on January 31, 2025.

“Our rural veterinarians are central to providing educated advice and helping manage and monitor livestock disease on farm, and therefore rural veterinary sustainability is paramount to the economic success and viability of Australia’s agriculture sector - one simply cannot exist without support from the other,” said Dickinson.

“Livestock graduates work largely unsupported and exposed, often needing to admit ‘failure’ to expectant producers, making farm work stressful and significantly impacting self-confidence. The large financial burdens associated with veterinary degrees and lower wages and income generation potential - compared to metropolitan companion animal clinicians, compound this stress. Mental well-being support is therefore also essential,” she concluded.

Funding for veterinary social worker training

The Veterinary and Community Care charity, which addresses the gap between vulnerable communities and access to essential veterinary care in Western Australia (WA), has received a landmark AU$279,500 funding commitment from the Western Australian Government to support its Veterinary Social Work Training and Services Pilot Project.

The 18-month pilot program, starting in early 2025, will train the first cohort of veterinary social workers in Western Australia. The Veterinary Social Worker Program aims to improve the health and wellbeing of animals and their caregivers, particularly those experiencing vulnerabilities such as homelessness, domestic violence, or financial disadvantage.

“This funding commitment from the WA Government is a game-changer for Veterinary and Community Care and the communities we serve,” said Paul Davey, OAM, BSc BVMS, director of veterinary and community care, in a media statement.1

“We are excited to develop the Veterinary Social Work program and provide critical support to people, their animals and the veterinary teams that serve both,” said Robyn Whitaker, BSc, BVMS, director and chair of Veterinary and Community Care.

WA Government announces support for Veterinary and Community Care’s pioneering Veterinary Social Work Program. News release. Veterinary and Community Care. September 16, 2024. Accessed September 30, 2024. 

Veterinary scene down under: Supporting new veterinarians and veterinary social work

Dr Christopher G Byers explains oxidative stress and EPO synthesis in CKD patients

Dr Byers dvm360 CKD interview Fetch on Demand

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Chronic kidney disease (CKD) affects a significant amount of animals across the nation. In an interview with dvm360, Christopher G. Byers, DVM, DACVECC, DACVIM (SAIM), CVJ, explains how oxidative stress can damage kidney tubular cells and lead to further kidney injuries. He also explains how CKD can diminish the kidney's capacity to generate erythropoietin (EPO), which is crucial to the creation of new red blood cells.

Christopher G. Byers, DVM, DACVECC, DACVIM (SAIM), CVJ:

 So, unquestionably, oxidative stress can cause damage to kidney tubular cells, which can lead to kidney injury. The kidney cells are truly vulnerable to oxidative stress because there's lots of mitochondria, and it's the mitochondria that are damaged by oxidative stress, and so we can see renal tubular function affected deteriorated by various oxidative stressors that occur in the body. And we are now learning that we can measure some of these markers of oxidative stress, as we serially monitor patients with chronic kidney disease.

Videos

Christopher G. Byers, DVM, DACVECC, DACVIM (SAIM), CVJ, explains the effects of oxidative stress on tubular cells and how EPO synthesis leads to non-regenerative anemia in CKD patients

Oxidative stress and EPO synthesis in CKD patients

Lucy Sumners, RVT, VTS(ECC), discusses technician care for patients with acute kidney injury.

Technician care for kidney injury

Lucy Sumners, RVT, VTS(ECC), a lead veterinary technician specialist at the University of Florida Small Animal Hospital in Gainesville, presented an education session on acute kidney injury management at the 2024 Southwest Veterinary Symposium in Fort Worth, Texas. In an interview with 

®, she discussed the veterinary technician’s role in caring for patients with acute kidney injury.

The following is a transcript of the video:

: My goal with this talk is also to empower technicians, kind of wherever they are at it doesn't have to be emergency. They can be in specialty or they can be in general practice, because these patients are going to be seen anywhere at some point in their kind of range as they go through and so the nursing care that I wanted to kind of empower them with this is early recognition. So for patients that come in that have a little bit of elevation in their kidney values. Where is it coming from? Do we have a concurrent heart disease? Is there a heat stress event? Is there an infectious process?

And then, if therapies are started at your clinic, what can you do to monitor how well your therapies are working? So the easiest way, and what people forget, is that you can do body weights on the patients, and it is no extra cost. It is very non invasive, but you can tell just by their body weight and their urine output, if they are in fact, if their kidneys are functioning or if they're even producing urine at the same time. 

You don't have to have any fancy equipment just to scale, and so I just wanted to emphasize that you don't need to be at a teaching hospital in order to take care of these patients, but the nursing care that goes into it for these guys is a lot of just kind of comfort. They can be very uncomfortable, very nauseous, painful, because kidney pain is pretty significant. And so the the kind of tender, loving care aspect of nursing care is really important for these guys, making sure they have adequate nutrition, adequate water. We're the ones that are working with them minute to minute, and so we'll see if they're nauseous as we do something, or if they all of a sudden become painful, or if their mentation changes, and we can alert the doctors to those changes and kind of make suggestions as we go through.

Lucy Sumners, RVT, VTS(ECC), discussed management of acute kidney injury at the 2024 Southwest Veterinary Symposium and in an interview with dvm360.

Technician care for acute kidney injury

Preventing the spread of a respiratory pathogen in a veterinary hospital has always been a challenge. When a patient exhales or barks, they expel a respiratory plume that contains a mix of gases, aerosols, and droplets. Pathogens are carried within these aerosols and droplets and can rapidly spread throughout the hospital.

The patient is often in multiple areas of the hospital from the time they enter the lobby until they are discharged. To isolate the patient, many hospitals will leave the patient in the examination room as much as possible. Once the patient has been discharged or hospitalized, the exam room is left closed for 24 hours and is cleaned multiple times during this period. This protocol leaves the hospital down an exam room and may contribute to the spread of respiratory pathogens.

There are multiple ways infectious diseases spread, including via vectors, fomites, direct contact, and fecal-oral and aerosol transmission. Of these, aerosol transmission is perhaps the most challenging to control in the veterinary setting. Prevention of disease transmission via respiratory droplets or aerosols is difficult, if not impossible, to achieve with isolation alone. In veterinary medicine, there are multiple papers available that discuss airborne transmission of pathogens; however, most focus on livestock and poultry.

Veterinary research that investigates the control of small animal pathogens typically includes a review of transmission, replication, clinical signs, treatment, facility design, isolation protocols, and vaccination.

 Multiple factors affect the spread of a respiratory pathogen, and the advent of COVID-19 has led to the publication of numerous research papers that investigate these factors.

 It is necessary to extrapolate and apply information obtained in human research for our purposes because of a deficiency of information specific to veterinary medicine.

The deposition of droplets and aerosols is dependent on their size. Expelled respiratory fluid greater than 5 μm is considered a droplet and will fall to a surface within several minutes. Expelled respiratory fluid less than 5 μm is an aerosol and will remain suspended in the air for several hours.

Asadi et al found the average diameter of particles expelled during breathing to be 1 μm, falling into the category of an aerosol.

 Based on similar respiratory mechanics in humans and small animals, it can be extrapolated that the average particle size expelled from a small animal patient during breathing is likely comparable.

The probability of the transmission of a disease via respiratory secretions can be calculated mathematically using the Contagion Airborne Transmission inequality formula.

 This complex equation is used in human research and allows multiple factors to be considered when calculating the likelihood of transmission of a pathogen. Included in this equation are several environmental factors, including temperature, relative humidity, air movement, air filtration, and the deposition of respiratory secretions. Viruses tend to survive longer and spread more easily at lower temperatures because of a delay in decay.

 Additionally, if the exhaled aerosol plume is warmer than the temperature of the room, it will rise and be caught in air currents that then move throughout the hospital.

Relative humidity has a profound and complex effect on the spread of pathogens, and it is important to mention that relative humidity contributes to the speed at which a particle will dehydrate, which is a critical factor. Larger droplets will land on a surface before they dehydrate, depositing pathogens on the surface. Smaller aerosols dehydrate while still suspended in the air, leaving the pathogens contained inside airborne, along with the lipids, albumins, and other fluids, thus increasing the risk of transmission.

Multiple studies have shown that relative humidity affects the spread of respiratory aerosols and droplets, in that a lower relative humidity (< 50%) will decrease the time required for a droplet to evaporate and increase the speed at which it dehydrates.

 Respiratory aerosols as small as 1 μm will evaporate in less than 1 second,

 which allows them to remain suspended in the air for a longer period, increasing the likelihood of infection.

At a higher relative humidity, the aerosol or droplet may absorb water and increase in size, causing it to fall to a surface more quickly.

 Additionally, relative humidity appears to affect the survival of viruses and bacteria differently, making it difficult to determine the ideal relative humidity to help prevent or decrease transmission.

Air currents also play a role in determining where a respiratory aerosol will travel. When a patient breathes, coughs, or vocalizes, a humidified plume of virus-laden respiratory aerosols and droplets are expelled. These plumes leave the upper respiratory system at varying speeds and trajectories. During normal respiration, plumes are released at a low speed, whereas vocalizing or coughing releases the plume at higher speeds.

 The initial speed at which the plume leaves the respiratory tract will determine how far the aerosols travel, in that those expelled with a higher speed will be carried farther.

 One study from human medicine showed that as the volume of speech increases, the volume of the air plume expelled increases consequently, increasing the number of viral particles expelled. It is expected that a barking dog would release a larger number of viral particles compared with a dog breathing normally.

These infectious aerosols are airborne, and they readily move with air currents. Every time the heating, ventilation, and air conditioning (HVAC) system turns on or the door to an exam room is opened or closed, an air current is created, carrying pathogens throughout the hospital. Although it is not practical to eliminate air currents, an area of focus can be decreasing the number of pathogens in the air.

One study that looked at the transmission of airborne pathogens on public transportation found that the installation of adequate filters in the HVAC system resulted in a 93.95% reduction in the aerosol particle count compared with the count obtained before filters were installed.11 Although some HVAC systems are easily updated with new filters, installing new filters throughout a building may not be practical. One alternative is the placement of an air purifier in the exam room.

A 2020 study observed a patient with a respiratory rate of 12 breaths per minute and a tidal volume of 1 L emitting 22,500 virions in 15 minutes. The use of a local air purifier decreased the virions in the air to 9000 within that 15-minute period, showing that the air purifier removed more than 50% of the airborne virions.

However, choosing an air purifier can be daunting. Ideally, the air purifier would include a high-efficiency particulate air (HEPA) filter and prefilters (class F7 and/or F9), which will capture larger particles (> 10 μm) and extend the life of the HEPA filter. The Clean Air Delivery Rate (CADR) is the amount of cubic ft of air the machine will filter in 1 minute and is based on how much air flows through the filter and the efficacy of that filter. Home air purifiers will have a CADR for smoke (0.09-1 μm), dust (0.5-3 μm), and pollen (5-11 μm). Some researchers have recommended a purifier with a CADR of 1000 or above for the classroom setting.

 It is also recommended that the CADR be 2/3 used in that exam room can be lower. The HEPA filters should be changed every 4 to 8 weeks, and the prefilters will require weekly visual inspection and should be cleaned or replaced as needed.

The larger droplets that hit a surface before they dehydrate will leave their pathogens on the surface on which they fall. Most pathogens we see in veterinary medicine are susceptible to multiple disinfectants, and surfaces should be cleaned as recommended by the manufacturer of the disinfectant used at your hospital.

At the author’s hospital, air purifiers were selected based on room size needs, and the air purifier is turned on when a suspect infectious patient enters the exam room. When the patient leaves the room, the door remains closed with the air purifier running for 30 minutes. At the 30-minute mark, the air purifier is turned off, surfaces are cleaned, and the room is opened to the next patient.

At the time this paper was written, in fall 2023, an unknown respiratory outbreak was present. The hospitalized infectious patients were housed together in 1 ward and strict isolation protocols were followed. Based on the size of the room and the number of patients housed, 2 air purifiers were placed in the ward and were left running 24 hours a day. A formal review of cases was not pursued; however, no patients coming into the hospital during this time developed clinical signs associated with the respiratory outbreak.

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Placement of an air purifier in an exam room used by patients with respiratory infections helps decrease the time the exam room is closed